Chronic Pain: Evaluation and Management

Three (3.0) Contact Hours

Expires: 10/31/2017

First Published: 5/2/2014

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Acknowledgements RN.com acknowledges the valuable contributions of... ...Kim Maryniak, RNC-NIC, BN, MSN. Kim has over 24 years nursing experience with medical/surgical, psychiatry, pediatrics, and neonatal intensive care. She has been a staff nurse, charge nurse, educator, instructor, and nursing director. Her instructor experience includes med/surg nursing, mental health, and physical assessment. Kim graduated with a nursing diploma from Foothills Hospital School of Nursing in Calgary, Alberta in 1989. She achieved her Bachelor in Nursing through Athabasca University, Alberta in 2000, and her Master of Science in Nursing through University of Phoenix in 2005. Kim is certified in Neonatal Intensive Care Nursing and is currently pursuing her PhD in Nursing. She is active in the National Association of Neonatal Nurses and American Nurses Association. Kims current and previous roles in professional development included nursing peer review and advancement, education, use of simulation, quality, and process improvement. Her most current role included oversight of professional development, infection control, patient throughput, and nursing operations. Kim has previously created and presented programs for pain assessment and management.

Conflict of Interest RN.com strives to present content in a fair and unbiased manner at all times, and has a full and fair disclosure policy that requires course faculty to declare any real or apparent commercial affiliation related to the content of this presentation. Note: Conflict of Interest is defined by ANCC as a situation in which an individual has an opportunity to affect educational content about products or services of a commercial interest with which he/she has a financial relationship.

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Purpose and Objectives The purpose of this course is to provide a brief review of pain components, and discuss assessment and management of chronic pain conditions. Material protected by copyright

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After successful completion of this course, you will be able to:

Review basic physiology of pain.

Review appropriate components of pain assessment.

Identify management options, including pharmacologic and non-pharmacologic interventions to alleviate chronic pain.

Describe considerations of chronic noncancer pain, neuropathic pain & cancer pain.

Discuss common barriers to effective pain management. Introduction Pain is individualized and subjective, that affects patients in a holistic fashion. It can alter the physical, psychological, social, spiritual, and cultural well-being of any patient. Chronic pain is multidimensional and unique to each patient, making it complex for evaluation and management. This course will cover material associated with assessment and management of chronic pain with adult and pediatric patients. Pain in the neonate is outside the scope of this course. For more information on other pain topics, refer to other courses available on RN.com, including Pain Assessment and Management and/or Acute Pain: Evaluation and Management. Types of Pain Pain is categorized as nociceptive or neuropathic, depending on the underlying pathophysiology. Patients who experience chronic pain may have both nociceptive and neuropathic processes occurring. Nociceptive pain transpires from nociceptor response to noxious stimuli, which can occur in the superficial or deep tissues (somatic) or in the visceral organs (visceral). The central nervous system functions appropriately with nociceptive pain. Superficial somatic pain is caused by external events that may be mechanical, chemical, or thermal. Examples may include surgery, burns, cuts, contusions, abrasions, injections, or dermatological disorders. Deep somatic pain may result from mechanical injury, overuse, inflammation, or ischemia. Examples include arthritis, tendonitis, or otitis media. Some examples of visceral pain include appendicitis, pancreatitis, gastric ulcer, bladder distension, or sickle cell disease. Neuropathic pain, also known as pathologic, pain is caused by injury or impairment of the central or peripheral nervous systems. This causes abnormal pain signals which can cause diffuse pain, making it difficult to determine the source (American Pain Society, 2007). Examples of neuropathic pain include diabetic neuropathy, neuralgia, carpal tunnel syndrome, phantom limb pain, post-stroke, or autoimmune disorders (such as multiple sclerosis or fibromyalgia). Test Yourself Which type of pain is associated with abnormal signals in the peripheral or central nervous system? Neuropathic - Correct Visceral Somatic Review: Description of Chronic Pain Material protected by copyright

Pain can be classified as acute or chronic. Chronic pain is described as pain that persists at least three months beyond the expected course of an acute injury or illness. Chronic pain can also disrupt activities of daily living and sleep, and has no protective purpose. It can be difficult to identify underlying pathology and explain the presence and/or extent of chronic pain, and it can be affected by factors that are not related to the cause (including psychological). Chronic pain may be present without physiologic signs, and can be incessant or periodic, with or without acute exacerbations (Alexander, 2013; American Pain Society, 2007). Acute and Chronic Pain A patient with a chronic illness may also experience acute pain. This could be from a separate disease process or trauma, or related to the chronic process. When an acute episode occurs from the chronic disorder, it is known as breakthrough pain. This can also be an increase in the intensity of the chronic pain. Each new pain episode should be assessed and evaluated separately. A completely different pain regimen may be needed to manage the acute pain, and there may be a separate cause for this pain. Making an assumption that the acute pain is simply related to the chronic process can be detrimental to the patient. Pain Assessment Pain is often referred to as the fifth vital sign, and should be assessed regularly and frequently. Pain is individualized and subjective; therefore, the patients self-report of pain is the most reliable gauge of the experience. A patient who has experienced chronic pain is very self-aware of their body and the effects of pain. Components of pain assessment include:

History and physical assessment (including subjective and objective information, medication history, and history of pain relief measures)

Functional assessment (including subjective and objective data of how pain impacts the patients ability to function)

Psychosocial assessment Multidimensional assessment

Test Yourself History components that are required as part of assessment include: History of substance use History of medications Medical history All of the above - Correct Multidimensional Assessment Many tools are available for an in-depth, multidimensional pain assessment. This is particularly important with patients that have chronic pain, mixed pain (both acute and chronic), or complex situations (such as multiple disease processes). Common examples of these tools include:

Brief Pain Inventory: Provides patient input in describing pain and effects, including psychosocial components. Can be viewed here.

McGill Pain Questionnaire: Patients can use descriptors for their pain, which provides information about the experience and intensity. The questionnaire can be viewed here.

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Pain Anxiety Symptoms Scale: Patients answer questions that relate to chronic pain and related anxiety. Can be viewed here.

Pain Outcomes Questionnaire: Provides information about functional subcategories of pain, and looks at outcomes. Can be viewed here.

Global Pain Scale: Patients rate current, recent, and average levels of pain. Psychosocial and functional questions are also asked. Can be viewed here.

Further Assessment Chronic pain is described as pain that extends beyond the period of healing, which can disrupt normal activities of daily living, sleep, and degrades health and functional capability. It is important to perform more in-depth assessments to determine how chronic pain affects these aspects of a patients life, including their quality of life. Common examples of these tools include: American Pain Association Quality of Life Scale: Patients provide information about how pain

affects their daily activities and ability to function. Can be viewed here.

CHANGE Pain Scale: Patients rate their current and acceptable levels of pain with a numeric scale, and identifies the impact of pain on everyday living. Can be viewed here.

Patient Health Questionnaire (PHQ-9): Patients provide information on their current levels of depression, which can be a detrimental effect of chronic pain. Can be viewed here.

Mini Mental Status Exam (MMSE): This gives a series of tests and exams, which can determine if cognitive functioning has been affected by chronic pain. Can be viewed here.

Pain: Verbal Reports Conducting an in-depth pain assessment will assist you in developing a comprehensive pain management plan. If patients are able to communicate, it is import to incorporate verbal reports of pain using descript